1、,休克患者(hunzh)血容量监测,第一页，共六十五页。,内容简介,容量(rngling)管理的基本目标容量监测的现状及局限性容量监测的进展ITBV的应用SVV的应用EVLW的应用小结,第二页，共六十五页。,休克(xik)的概念,感染、创伤、烧伤等引起有效循环血量明显减少组织器官的灌注不足氧输送不能满足组织代谢(dixi)需要导致组织缺氧代谢障碍和细胞受损临床综合征,第三页，共六十五页。,休克治疗的首要任务：积极(jj)、合适补充血容量,休克发生(fshng)的始动因素：有效循环血量下降,合适的容量(rngling)管理,第四页，共六十五页。,容量管理的基本(jbn)目标,保证容量合适(hsh
2、)的心脏前负荷,预防(yfng)肺水肿,二者必须平衡,第五页，共六十五页。,内容简介,容量管理的基本目标容量监测(jin c)的现状及局限性容量监测的进展ITBV的应用SVV的应用EVLW的应用小结,第六页，共六十五页。,容量监测(jin c)的现状,容量监测(jin c)：TEE，CT，核素扫描临床表现:血压、心率、尿量、皮肤粘膜等压力监测：漂浮导管(CVP/PAWP),心脏(xnzng)前负荷：VEDV,第七页，共六十五页。,第八页，共六十五页。,RVEDP/LVEDP的测定(cdng),第九页，共六十五页。,压力反映(fnyng)容量及肺水肿的局限性,心脏顺应性瓣膜(bnm)功能肺毛细血
3、管通透性机械通气对循环的影响,PAC对容量(rngling)监测的有效性和可信性受到置疑？,第十页，共六十五页。,许多文献：CVP/PAWP不能准确反映(fnyng)容量状态,第十一页，共六十五页。,Principle of EVLW measurement,RAEDV,LAEDV,LVEDV,PBV,RVEDV,EVLW,Injection,PiccoThermo-dilutioncatheter,Swan-ganz catheter,呼吁容量(rngling)指标的应用来反映容量状态及肺水肿,第十二页，共六十五页。,内容简介,容量管理的基本目标容量监测的现状及局限性容量监测的进展(jnzh
4、n)ITBV的应用SVV的应用EVLW的应用小结,第十三页，共六十五页。,A physiological system model,ITTV:Intrathoracic total volume,GEDV:Global end-diastolic volume,ITBV:Intrathoracic blood volume,PTV:Pulmonary total volume,EVLW:extra-pulmonary lung water,胸內总容量(rngling),全心舒张(shzhng)期血容量,胸內血液(xuy)容量,肺部容积,血管外肺水,第十四页，共六十五页。,容量(rngling)
5、指标的应用,胸腔内血管容量(rngling)(ITBV)血管外肺水(EVLW)搏出量变异率(SVV),第十五页，共六十五页。,胸腔(xingqing)内血管容量(ITBV),左心舒张(shzhng)末期容量右心舒张末期容量肺血容量,第十六页，共六十五页。,搏出量变异(biny)率(SVV),SVV=(SVmax SVmin)/SVmeanSvmax:mean value of four SVmax/30sSVmin:mean value of four SVmin/30sSVmean,第十七页，共六十五页。,血管(xugun)外肺水组成(EVLW),细胞内液间质液体(yt)肺泡内液体,第十八页
6、，共六十五页。,内容简介,管理的基本目标容量监测的现状及局限性容量监测的进展ITBV的应用(yngyng)SVV的应用EVLW的应用小结,第十九页，共六十五页。,ITBVvalid estimate of preload in ALI,Prospective animal study15 sheep with ALI-saline washoutMV(PEEP 0,7,14,21 respectively 60min)Measurement:LVEF,LVEDV-CT scanITBV,RVEDV-PiCCOCVP,PAWP-PAC,Luecke T,et al.Intensive Care
7、Med,2004,30:119-126,第二十页，共六十五页。,Luecke T,et al.Intensive Care Med,2004,30:119-126,第二十一页，共六十五页。,Luecke T,et al.Intensive Care Med,2004,30:119-126,ITBV and RVEDV Provide valid estimate of preloadEven at high intrathoracic pressure,第二十二页，共六十五页。,ITBV-indicator of preload in liver transplantation,60 pati
8、ents undergoing Liver transplantation monitored with PiCCO and PACthe correlation between PAOP and ITBVI with respect to CI and SVIthe correlation between ITBVI and PAOP,Della Rocca G,et al.Eur J Anaesthesiol.2002,19:868-75,第二十三页，共六十五页。,ITBVI-more reliable indicator of preload than PAWP,Della Rocca
9、G,et al.Eur J Anaesthesiol.2002,19:868-75,第二十四页，共六十五页。,ITBVI-valid indicator of preload in lung transplantation,50 patients during lung transplantationTime:6 phase during operationCorrelation between PAWP and SVICorrelation between ITBVI and SVICorrelation between(Delta)ITBVI PAWP and Delta SVIDelta
10、 were calculated by subtracting the first from the second measurement Della RG,et al.Anesth Analg.2002,95:835-43,第二十五页，共六十五页。,ITBV-superior than PAWP in preload,Della RG,et al.Anesth Analg.2002,95:835-43,Correlation of ITBV-SV in 4 phases,No correlation of PAWP-SV in any phases,第二十六页，共六十五页。,Prospect
11、ive,controlled,clinical study18 patients with ejection fraction 50%undergoing coronary artery bypass graft surgeryA baseline measurement:after induction of anesthesia(T1)treated by infusion of 6%hydroxyethyl starch 200/0.5(7 mL/kg)After 10 minutes,a second measurement(T2)was performed,Wiesenack C,et
12、 al.Cardiothorac Vasc Anesth.2001,15:584-8,ITBV correlated significantly with CI and SV IN CABG,第二十七页，共六十五页。,ITBV has Good relationship between CI/SVI,CVP/PCWP 与 CI/SV无相关性,ITBV 与 CI的相关性r=0.55,ITBV 与 SV的相关性为r=0.62,Wiesenack C,et al.Cardiothorac Vasc Anesth.2001,15:584-8,第二十八页，共六十五页。,前瞻性临床研究40例心脏(xnzn
13、g)移植术后患者男34例，女6例观察术后3、6、12、24、36、48、72h ITBV/GEDV和CVP/PAWP与SV的相关性,ITBV/GEDV-good preload indicator in heart transplantation,Goedje O,et al.Chest,2000,118:775-781,第二十九页，共六十五页。,Goedje O,et al.Chest,2000,118:775-781,第三十页，共六十五页。,Goedje O,et al.Chest,2000,118:775-781,GEDV-SV:R2=0.4016ITBV-SV:R2=0.2979,第三
14、十一页，共六十五页。,Goedje O,et al.Chest,2000,118:775-781,PAWP-SV:R2=0.0043CVP-SV:R2=0.0552,第三十二页，共六十五页。,ITBV的改变反映(fnyng)肺水含量,Prospectively study16 patients with septic shock and pulmonary edema(ACCP/SCCM)SAPS II:56Monitor:Picco,PACOptimal PAWP:CI no longer increasedMonitor time:0,24hIntensive Care Med,2002,
15、28,712-18,第三十三页，共六十五页。,From intensive Care Med,2002,28,712-18,CVP与EVLW的相关性,PAWP与EVLW的相关性,第三十四页，共六十五页。,Correlation between ITBV/TEDV and EVLW,From intensive Care Med,2002,28,712-18,ITBV 与 EVLW有良好(lingho)相关性优于 CVP 与 PAWP,第三十五页，共六十五页。,内容简介,容量管理的基本目标容量监测的现状及局限性容量监测的进展ITBV的应用(yngyng)SVV的应用EVLW的应用小结,第三十六页
16、，共六十五页。,SVV可以反映(fnyng)机体前负荷,Prospective study20 MV patients following cardiac surgeryVolume loading(HES 20ml*BSA/10min)Measurement:CVP,PAWP-PACLVEDAI-TEEITBV,SVV-PiCCO,Reuter DA,et al.Intensive Care Med.2002,28:392-8.,第三十七页，共六十五页。,血流动力学监测(jin c),第三十八页，共六十五页。,SVV may help to determine the preload condition,Reuter DA,et al.Intensive Care Med.2002,28:392-8.,CVP/PAWP not correlated with CI,第三十九页，共六十五页。,SVV may help to determine the preload condition,Reuter DA,et al.Intensive Care Med.2002,28:392-8.,
